Care Coordinator

Care Coordinator

Behavioral Health Community Partners - New Bedford
Associates degree or related field with 2 years experience
Pay Range: $17-$25.50
FT - 40 hours

Benefits

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Long & short term disability
• Discounted auto/home and renters insurance
• 403b - Retirement
• FSA & DSA
• PMLA
• Employee Assistance Program
• Bonuses & Referral
• Eligibility for free classes to become a Licensed Counselor or Recovery Coach
• Education days to use towards CEU's
• Free meals at select programs and when available
• Unmatched Leave Time (FT employees can earn up to 3 weeks in first year)

Community-based and human services organizations (Community Partners) working with accountable and managed care organizations to integrate care and improve health outcomes for MassHealth members with " complex long-term and/or behavioral health needs."

High Point & Affiliated Organizations is a health and human service agency whose mission is to treat and prevent substance use disorders and mental illness. High Point has programs located throughout Southeastern Massachusetts offering a full continuum of care for substance use and mental health treatment, including inpatient, outpatient, residential, and community-based services. Programs and services also assist survivors of abuse, violence, and families experiencing homelessness. High Point believes that everyone has inherent goodness, worth, and dignity. Our goal is to help individuals and families achieve personal change and improve their quality of life.

Care Coordinator Requirements:

• Will be responsible for providing care coordination to enrollees. These individuals may have lived experience;
• Proficiency in communication technologies (email, writing skills, cell phone, etc.);
• Highly organized with the ability to keep accurate notes and records;
• Driving Requirements: valid drivers’ license; must be 21; regular access to reliable transportation required; driving report from Registry of Motor Vehicles upon hire;
• Experience with EMR systems and reports is desirable;
• Local knowledge about and connections to community health care and social welfare resources is desirable;
• Ability to speak a relevant second language is desirable.

Care Coordinator Duties and responsibilities:

• The Care Coordinator works in collaboration and continuous partnership with chronically ill or “high risk” enrollees and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach to:
  • Serve as the contact point, advocate, and informational resource for enrollees, care team, family/caregiver(s), payers and community resources;
  • Work collaboratively and effectively with care management team, including Assigned or Engaged Enrollees, their family/caregiver(s), medical team and other providers to coordinate BH care management services.
• Work with enrollees to plan and monitor care;
• Complete Comprehensive assessments for all Engaged enrollees;
• Facilitate approval of the Comprehensive Assessment within 90 days of Enrollee’s assignment;
• Develop a care plan with the patient, family/caregiver(s) and providers (emergency plan, health management plan, medical summary and ongoing action plan, as appropriate) within 90 days of Enrollee’s Assignment. Update the plan at least every 6 months;
• Monitor adherence to care plans, evaluate effectiveness, monitor patient progress in a timely manner, and facilitate changes as needed;
• Create ongoing processes for patient and family/caregiver(s) to determine and request the level of care coordination to support their desire at any given point in time;
• Ensure the plan meets the requirements of EOHHS and notify the ACO/MCO if changes have occurred, since the completion of the Comprehensive Assessment;
• Facilitate patient access to appropriate medical and specialty providers;
• Educate patient and family/caregiver(s) about relevant community resources;
• Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources as needed;
• Ensure that the Engaged Enrollee receives the necessary assistance and accommodations to prepare for, fully participate in and to the extent preferred, direct the treatment planning process;
• Ensure the Engaged Enrollee receives assistance in understanding BH terms and BH concepts, including but not limited to information on their functional status; how family members, social supports and other individuals of their choosing can be involved in the treatment planning process; self-directed care options and assistance available to self-direct care; and BH services or programs that are available to meet their needs and for which they are potentially eligible;
• Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up and integration of information into the care plan regarding transitions-in-care and referrals;
• Assist with the identification of “high-risk” enrollees (the chronically ill and those with special health care needs), and flag in the EMR;
• Conduct assessment for Flexible Services for all Engaged Enrollees who are enrolled in an ACO. If Flexible Services are identified, make recommendation to ACO for approval;
• Provide health and wellness coaching as directed by the Engaged Enrollee’s care team and as indicated in the Enrollee’s care plan;
• Maintain regular contact with Engaged Enrollee to monitor and coordinate care planning including quarterly face-to-face meetings;
• Complete all required documentation in a timely manner;
• Attend all Care Coordinator trainings and meetings;
• Execute duties to reflect reasonable safety standard. Standard precautions must be utilized and training obtained in areas that constitute risk;
• Perform other related work duties as needed or as assigned by supervisor.

Care Coordinator Qualifications:

• 1 year of experience working with mental health/substance use disorders with a Bachelor’s degree in a social services field; or
• 2 years of experience working with mental health/substance use disorders with Associates or no degree.